Guidelines recommend decision-making using the heart team (HT) in complex patients considered for myocardial revascularisation, but there are little data on how this approach works in practice. We data-mined our electronic HT database and selected patients in whom the clinical question referred to revascularisation, and documented HT recommendations and their implementation.
We identified 154 patients (117 male), mean age 68.9 ± 11.4 years, discussed between February 2019 and December 2020. The clinical questions were coronary artery bypass graft (CABG) versus percutaneous coronary intervention (PCI) (141 cases, 91%), and medical treatment versus revascularisation by PCI (eight cases, 6%) or by CABG (five cases, 3%).
HT recommended CABG in 55 cases (35%), PCI in 43 (28%), medical treatment in 15 (10%), and equipoise in seven (5%) and further investigations in 34 (22%): non-invasive imaging for ischaemia in 11 (32%), invasive coronary physiology studies in eight (24%), further clinical assessment in seven (20%), structural imaging for five (15%), invasive coronary angiography in two (6%), and an electrophysiology opinion in one case (3%).
Decisions were implemented in 135 cases (89%). The average time between the HT and the implementation of its decision was 80.5 ± 129.3 days. There were 17 deaths: 10 cardiac, six non-cardiac and one of unknown cause. Patients who survived were younger (68.6 ± 11.3 years) than those who died (73.8 ± 10.0 years, p = 0.03).
In conclusion, almost 90% of the decisions of the HT on myocardial revascularisation are implemented, while ischaemia testing is the main investigation required for decision-making. Recent data on the futility of such an approach have not yet permeated clinical practice.
Introduction
Contemporary cardiology guidelines often recommend that decision making should take place by discussions within a multi-disciplinary heart team (HT), particularly in complex patients.1,2 However, very little data exist about the effectiveness of such an approach, about the extent to which HT decisions are implemented, or about the outcome of patients being managed according to decisions made by the HT.
We set out to analyse the decisions of our revascularisation HT in a medium-sized regional tertiary centre, in order to optimise our processes, and also to explore the extent to which the HT decisions were actually carried out.
Method
Setting
Morriston Cardiac Centre is a regional tertiary centre that serves a population of approximately one million, in West Wales, UK. Pre-pandemic, it performed approximately 2,500 coronary angioplasties and 750 open-heart procedures per year. There are 10 interventional cardiologists and five cardiac surgeons. A weekly HT meeting has been in operation since the inception of the centre in 1998, but its deliberations are formalised and documented in a dedicated database (Solus, HD Clinical, Stanstead, UK) only since February 2019.
Inclusion criteria
We included all patients discussed at the HT between 1 February 2019 and 31 December 2020 in whom the clinical question was related to myocardial revascularisation. Patients could be referred to the HT both by cardiologists in Morriston and in secondary cardiac centres in the region served by Morriston.
Aim of the study
We documented demographic characteristics of the patients, as well as the decisions of the HT, and we data-mined clinical and electronic records to find out whether, and to what extent, the decisions of the HT were implemented. In cases where the HT could not formulate a treatment recommendation because it required additional information, we documented the type of information required. Where the HT decisions were not carried out, we identified the reasons for that. We documented the time elapsed between the date of the HT decision and its implementation (date of revascularisation procedure); for patients treated without revascularisation we used the date when the HT decision was first mentioned in correspondence about the patient. We identified the survival status of the patients and calculated the length of survival between the date of the HT and our censoring date, 21 December 2021.
Composition of the HT
The quorum required for the HT was two interventional cardiologists and two cardiac surgeons.
Results
Patient characteristics
We identified 152 patients (116 male, 76%), mean age 68.8 ± 8.8 years, discussed between February 2019 and December 2020; 109 referred by Morriston consultants and 43 by external consultants. There were 33 consultants (two cardiac surgeons, 31 cardiologists) submitting an average of 5 ± 3.8, median 4, cases per consultant. Seven cardiology consultants (22%) accounted for 50% of the cases submitted.
Clinical questions
The clinical questions were whether revascularisation should be performed by coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) (140 cases, 91%), and whether medical treatment or revascularisation by PCI (eight cases, 6%) or by CABG (four cases, 3%) should be performed.
Additional testing
In 33 patients (22%) the HT required further information in order to formulate a treatment plan. The additional tests included functional testing for inducible myocardial ischaemia (12 cases), followed by intracoronary physiological testing (eight cases), clinical assessment in six cases, structural cardiac imaging in five cases, invasive coronary angiography in two cases, liver function tests and electrophysiology opinion in one case each; one patient had more than one test.
Decisions of the HT
When the HT could formulate a recommendation for treatment without requiring any further information (in 119 cases, 78% of the total number discussed), this was for CABG in 54 cases (45%), for PCI in 42 cases (35%), and for medical treatment in 16 (13%). In seven patients the HT recorded equipoise between CABG and PCI, with the final decision to be taken by the patients involved, after discussion with the cardiac surgeon and cardiologist. In 16 of the patients in whom a treatment plan could be formulated, the HT also requested further tests: functional testing for inducible myocardial ischaemia in six patients, invasive coronary physiological testing in five, structural imaging and invasive coronary angiography in two for each, and biochemical liver function tests in one patient.
Implementation of HT decisions
The decisions of the HT were implemented in 135 cases (89%), while in 17 cases they were not. Of these, eight patients had PCI rather than CABG (patient preference or clinical instability prompting unplanned PCI), three patients switched from medical treatment to PCI because of uncontrolled symptoms, two had CABG instead of PCI, and in each of the following categories there was one patient: CABG instead of medical treatment, medical treatment instead of PCI, and single-vessel PCI instead of two-vessel PCI (failure of chronic total occlusion [CTO] PCI). The average waiting time between the HT and the implementation of the HT decision was 80.5 ± 129.3 days, median 14 days.
Patient survival
There were 17 deaths: 10 with a cardiac cause, six non-cardiac and one of unknown cause. In eight cases the HT decision had been referral for CABG, in three for medical treatment, in another three for further investigations, in two for PCI, and in one there was equipoise and the patient had opted for CABG. Three of the deceased patients had been deemed too frail for any intervention. Patients who survived were younger (68.6 ± 11.3 years) than those who died (73.8 ± 10.0 years, p=0.03). Of the 17 patients who died, eight had interventions, as follows: two had PCI and died before discharge; four had cardiac surgery and died in the intensive therapy unit (ITU); one had only instantaneous wave-free ratio (iFR) and PCI was deferred; one died of complications of limb ischaemia, unrelated to the procedure, 11 months after PCI.
Discussion
In a regional tertiary centre serving a population of one million, the HT could reach a decision on myocardial revascularisation strategy, based on the information provided, in 78% of the cases, with CABG being more often recommended than PCI or conservative treatment. Non-invasive testing for ischaemia and intracoronary physiology testing were the most frequently requested tests before a decision could be reached. In patients in whom the decision of the HT was not implemented, this was due either to conversion from CABG to PCI or from conservative management to revascularisation.
The HT approach is based on the premise that it “… serves the purpose of a balanced multi-disciplinary decision process” (European Society of Cardiology [ESC] guidelines). Both US and European guidelines make a class 1 recommendation for the use of a HT in revascularisation decision-making, although this is supported by evidence of the lowest quality (level C). Thus, guidelines based on low-quality evidence postulate we should use an approach that is very different from the traditional process of referral from an individual cardiologist to an individual cardiac surgeon. The use of a HT discussion has been proposed to prevent inappropriate use or underuse of resources when managing coronary artery disease. Furthermore, with ever advancing subspecialisation within the field of cardiology, such as imaging, complex intervention, electrophysiology, etc., the HT provides a platform for these specialists to provide their valuable input in managing complex cases requiring revascularisation.
This fundamental shift in practice was ushered by the SYNTAX (Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) trial,3 which compared CABG versus PCI with drug-eluting stents in patients with complex coronary artery disease. At each participating centre a HT, consisting of an interventional cardiologist and a cardiac surgeon, evaluated patients’ eligibility for the study. However, extrapolating research methods to clinical practice is not necessarily safe or justifiable; priorities are different in these two settings, as is resource allocation and utilisation. Ideally, a rigorous study of outcomes and resource utilisation by the HT model should be undertaken before this approach is enshrined in guidelines.
Evidence is sparse both on the effectiveness of this approach and on its outcomes. A US study has shown that HT decisions correlate well with appropriateness of use criteria for myocardial revascularisation, but these are cumbersome and not really used outside the US.4 More comparable to our experience, a UK study by Pavlidis et al.5 looked at 399 patients discussed in 51 consecutive multi-disciplinary team (MDT) meetings held in a tertiary cardiac centre in London. Medical management was recommended in 30%, CABG in 6%, and PCI in 17%, while further information was needed in 25%; decisions were carried out in 93% of the cases. Of note is the male preponderance, which is noted both in our study as well as by Pavlidis et al.5 and in the SYNTAX trial,3 highlighting what is now a well-known phenomenon of gender disparity in diagnosis, management and treatment of coronary artery disease in women when compared with men. A subgroup of 40 patients was re-discussed using the same clinical data, at least six months after the initial discussion, and the same recommendation as initially provided was formulated in 80% of cases. These results are comparable to ours, with the notable difference that we had a lower rate of recommending medical treatment, perhaps as a reflection of recent progress in stent technology, although these differences may also stem from differences in the patient population; type of presentation (acute vs. stable) or comorbidities of the patient.
It is disturbing that in the study by Pavlidis et al. one in five patients received a different decision when resubmitted to the HT using exactly the same information as the first time, and points to the major weaknesses of any form of collective deliberation, which is susceptible to being highjacked by the participant with ‘the loudest voice’ and is vulnerable to groupthink, a ‘mode of thinking in which individual members of small cohesive groups tend to accept a viewpoint or conclusion that represents a perceived group consensus, whether or not the group members believe it to be valid, correct, or optimal’ (https://www.britannica.com/science/groupthink). It is important to note here that the composition of HT did change to various extents in the study by Pavlidis et al. and, therefore, conclusions regarding inter-observer and intra-observer reliability cannot be inferred. Furthermore, in their study, 25% of the resubmitted cases were recommended to undergo further diagnostic methods, which probably should not be construed as a definitive treatment recommendation.
One in five patients were referred for ischaemia testing (invasive and non-invasive) before a decision could be made. Increasingly strong evidence suggests that, at least in stable patients, revascularisation guided by ischaemia testing (once left main stem disease has been ruled out) does not improve symptoms and outcomes.6 Data are now accruing indicating the same lack of significance of ischaemia in patients with multi-vessel disease at the time of primary PCI.7 It is interesting to see that clinical practice is not yet significantly impacted by these paradigm-shifting recent trials.8
A limitation in our study has been the incomplete documentation of data on review of medical records with baseline characteristics, such as smoking status, diabetes, serum lipid levels, etc., not accurately recorded. This is now changing as the HT discussion is moving towards a redesigned comprehensive online form including all of the patients’ comorbidities to submit in order for the HT to discuss these cases. Another limitation is the limited number of cases discussed with the HT (157) compared with the overall number of patients undergoing revascularisation at our institution annually (over 2,500) at the time of data collection. The situation is now evolving with an increased proportion of cases being referred to the HT currently. It will be interesting to see how the additional data accrued from this affects our recommendations regarding revascularisation in the future.
Conclusion
Systematic research on the processes and outcomes of the HT is needed, as not much data are available to guide its deployment outside the research setting, and its effectiveness and safety have not been formally tested in large numbers of patients. Our own HT processes appear comparable with those in another UK tertiary centre, and can be made more efficient by ensuring the completeness of the clinical datasets used for decision-making. Ischaemia testing remains prevalent in spite of increasing evidence suggesting its lack of usefulness.
Key messages
- In a regional tertiary centre in West Wales, the use of a heart team multi-disciplinary approach to complex patients requiring revascularisation is comparable with a similar tertiary cardiac centre in the UK
- There remains a considerable dearth in data validating the heart team approach to revascularisation, and more studies are needed to validate this approach
- Ischaemia testing was the most prevalent test requested by the multi-disciplinary team for revascularisation, despite increasing evidence against its utility in non-left main lesions. This practice may require further review
Conflicts of interest
None declared.
Funding
None.
Study approval
Requirement for ethical approval and consent was waived by the local hospital audit department as the study is a retrospective analysis of anonymised patient data.
References
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2. Neumann F-J, Uva M, Ahlsson A et al. 2018 ESC/EACTS guidelines on myocardial revascularization. Eur Heart J 2019;40:87–165. https://doi.org/10.1093/eurheartj/ehy394
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